By VIPAN NIKORE, MD

I sat at home with a sense of relief. I had just finished my first month of residency – a grueling inpatient hospital month where I was pushed to new limits.  I now finally had my first “golden weekend” (meaning I had both Saturday and Sunday off). More importantly, I had survived my first month without any patient deaths on my service. Given how sick people are when they come to the hospital, I felt pretty good about this result.

That feeling lasted less than 24 hours. As I logged in from home onto the electronic medical record to finish some documentation, I realized one of my patients was in coma due to a sudden stroke. This patient had few clinical symptoms and appeared the healthiest amongst all the patients I managed the entire month. A heavy knot quickly developed in my stomach, as I could not shed the feeling that perhaps I did something wrong. I scoured the medical records, retracing my management. Over the next couple of days I discussed the case with other colleagues and experts in the field, and read in depth on the management of this condition.  To my relief it was clear that I did not nor did anyone involved in the patient’s care make an error in management. Unfortunately, however, this patient eventually passed away.

As I reflect on the experience, an important point stands out in my mind. This patient exhibited few signs of being “sick” and was managed very well by all the physicians during the course of the hospital stay, but died. On the other end of the spectrum are patients who appear incredibly sick, and despite a poor prognosis survive against odds. One of the goals of residency is to learn to assess a patient and quickly identify who is in imminent danger and may need immediate attention. Unfortunately, however, physicians cannot predict everything, as situations similar to the one above are not uncommon scenarios. Given this fact it makes the discussion about measuring healthcare and pay for performance very cloudy.

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